MDC 1 Exam 1, questions with complete solutions 2023

MDC 1 Exam 1, questions with complete solutions 2023 Maslow's Hierarchy of Needs (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization Assessment of Comfort Level ask patient if they are comfortable If they have physcial discomfort, assess level of pain and plan intervention if it's mental discomfort, have them describe the nature of the stress Interventions to prevent impaired comfort anticipate which patient may experience them and provide preplanned interventions pain 5th vital sign cutaneous pain superficial pain usually involving the skin or subcutaneous tissue visceral pain pain originating in the internal organs and is non localized deep somatic pain ligaments, tendons, bones, blood vessels, nerves radiating pain starts at an origin but spreads to other locations referred pain pain that is felt in a location other than where the pain originates phantom pain pain or discomfort felt in an amputated limb Assessment of Elimination -take patient history -monitor frequency, amount , and consistency Interventions to prevent changes in elimination adequate nutrition and hydration Interventions for patients with changes in elimination -Monitor pt for signs of fluid and electrolyte imbalance -adults experiencing urinary incontinence require frequent toileting -Patients with short term urinary retention require one or more catherization stress incontinence involuntary urine loss with physical strain, sneezing, or coughing urge incontinence loss of large amounts of urine accompanied with a strong urge to urinate overflow incontinence small amounts of urine leak from a full bladder functional incontinence the person has bladder control but cannot use the toilet in time unconscious incontinence loss of urine when the person does not realize the bladder is full and has no urge to void intake -measured in mLs -everything liquid output stools and urine Assessment of Fluid Balance -health hx -monitor vitals especially pulse rate and quality -assess skin and mucous membrane for dryness and decreased turgor Interventions to prevent fluid and electrolyte imbalance drink 8 glassess of water a day and eat a balanced diet Interventions for fluid imbalance fluid deficit: replace fluids fluid overload: restrict fluid Assessment of gas exchange -health hx and assess patients breathing efforts and pulmonary function test interventions to prevent decreased gas exchange teach infection control and to stop smoking interventions for someone with decreased gas exchange having them sit up Assessment of mobility ROM, gait and activity tolerance Interventions to prevent immobility -determine who is at a higher risk -teach patients to do ROM every 2 hours Drinking fluids to prevent DVT -evaluate need for assitive device Interventions for immobility -passive ROM -reposition patients every 2 hours -keep patient skin clean and dry Assessment for sensory perception -conduct a health hx and determine factors for any sensory loss and perform cranial nerve test Interventions to prevent loss of sensory perception -annual screening -use of protective devices Interventions for those with sensory perception loss -encourage compliance with medications -use of corrective devices -visually impaired need guide dogs and those who can't hear need hearing devices Assessment for Gas exchange -assess RR, O2 sat, breathing pattern -collect sputum culture and ABG -pulmonary function test Interventions to Promote Gas exchange -proper handwashing to avoid getting sick -stop smoking -vaccinations Interventions for those with decreased gas exchange -determine underlying issue -administer O2 -pulse oximeter -position patient in semi-fowlers position -deep breathing Assessment of perfusion -complete family and patient hx -ID symptoms of decreased central perfusion such as dyspnea and syncope and dizziness and cyanosis Interventions to promote perfusion -stop smoking -annual checks Interventions for those with decreased perfusion -educate on medication importance Assessment of Immunity -health hx -assess weight -wound healing -allergic responses -organ dysfunction Interventions to promote immunity -perform hand hygiene -avoid large crowds when sick -manage reactions -ID flare ups Assessment of Sexual health -collect sex history Intervention to promote sexual health -STI screening -use of condoms Interventions for those with decreased sexual health -determine root cause RICE rest, ice, compress, elevate 1st communication phase: pre-interaction begins with data collection and patient ID the need for healthcare 2nd communication phases for therapeutic relationship: Orientation -Goal is to establish rapport and trust via non verbal and verbal communication -INtro and nurse role is shared with patient -address patient with the preferred title and name 3rd communication phase: working -main goal is to maintain mutual respect and honesty, clarify, feelings 4th communication phase: Termination -goal is to review and summarize shared info -prepares for future interactions empathy -desire to understand and be sensitive to feelings -put yourself in their shoes Respect -expression of value and flexibility to meet patients needs -patient has the risk of suffering from low self esteem Genuiness -ability to respond truthfully -tell patient you don't have the answer if you dont know something Concreteness specific, definite, vivid confrontation used to clarify message received or decoding the actual meaning Silence -helps patient fully express and share important info -great for emotional patients establishing trust can lead to better communication, more easily relay information and share feelings being assertive -ability to express effectively their POV while respecting other beliefs and POV -5 steps: get persons attention, express concerns, state problem, propose an action and reach a decision Validating Messages -Restating: using your own words to summarize -Clarifying: ensure you decoded correctly by asking -Validate: confirm u have made the right interpretation Barriers to communication -asking too many questions -changing the subject -asking too many closed ended questions -expressing disapproval or approval -offering advice -false reassurance -stereotyping 3 major health beliefs -scientific (hospitals, medications, etc) -Magico-Religious: (rituals, supernatural forces, indigenous) -Holistic: need for harmony and balance of the body with nature yoga Archetype -something recurrent that makes beliefs that everyone has under the same racial or ethical group Ex. All Irish population will have reddish tone hair color. All Mexican will have brown eyes. All Europeans will have light color skin. Acculturation An individual assumes the characteristics of a culture they just immigrated too Nurse Cultural self-awareness be aware of your own bias Exploring Issues -Use open ended questions -Probing: tell me more...what do you mean Joint Commission goal is to ensure saftey and quality care is provided to all patients Center for Medicare and Medicaid Services (CMS) ensure proper quality of care is not overcharged Agency for Healthcare Research and Quality (AHRQ) Provides evidence-based information on health care outcomes; quality, and cost, use, and access. The information helps health care decision makers. American Nurses Association (ANA) Their goal is to foster high-standards of the nursing practices, promoting safe and ethical work environment, bolstering nursing health and wellness Infant/Toddler leading cause of death drowning Preschooler and school-aged children leading cause of death Car crashes Poisioning -Young Children: exposed due to improper storage of household chemicals -Older Children and adolescents: exposed due to suicide attempt or accidental experiment with drugs -Adults: misuse or abuse of drugs Suffocation smothering is the leading COD in those younger than 1 Storms Death caused by lightning strike is the lead cause of death due to weather; second is flooding Types of pathogens Food-borne: food poisoning, raw eggs and fish -water borne: poor sanitation, E. Coli -vector borne illness: mosquitos RACE (fire) R-rescue A-alarm C-confine E-extinguish PASS (Fire Safety) P - Pull the pin. A - Aim at the base of the fire, not at the flames. S - Squeeze the lever. S - Sweep the nozzle from side to side. Nursing Interventions of Poisoning activated charcoal orally or via gastric tube